A RWJF Collection

From the Bottom Up

This is one in a series of stories about the Robert Wood Johnson Foundation’s landmark achievements, which continue to inspire us as we address future challenges.

As many as 15 million people need another person's help with the everyday tasks most of us take for granted, such as making meals, eating, bathing, dressing, and toileting.

For decades, the “system” has responded to this need by directing hundreds of thousands of Medicaid recipients out of their homes, away from their families, and into nursing homes.

In short: The system knows best.

The relative few who did qualify for in-home care were allowed no say over who would help meet their daily needs, how and when those needs would be met, or even which were the most pressing needs.

We thought there was a better way. Our response: A modest program called Cash & Counseling, which is turning upside down the entrenched presumption that the poor, the old and the disabled are unable, unwilling, or too dishonest to responsibly manage the public funds spent on their in-home care.

We’re accustomed to our role as a national philanthropy, taking on huge top-down issues like strengthening the public health system, improving care quality, and reversing the epidemic of childhood obesity. But sometimes, to make a real difference in the life of a single vulnerable human being, we work from the bottom up—one person, one outcome at a time.